Claims determination process

After MCOs receive a report of an injury they send important information about the injury to BWC

After managed care organizations (MCOs) receive a report of an injury — from you, the injured worker or employer — they electronically send important information about the injury to BWC.

BWC assigns a claim number to the reported injury;

On-line filing receives claim number immediately;

If not online, the injured worker and employer will receive written notice of the claim number;

If you submit your provider number with the injury report to the MCO, you and the treating physician (if different) will receive written notice of the claim number.

Claim number assignment does not mean BWC has allowed the claim and medical bills will be paid. It just indicates that BWC has received the report of injury or illness.

Providers will receive payment for treating an injured worker only when BWC allows the claim. If BWC disallows the claim, providers will not receive payment for any treatments.

The MCO will work with BWC to resolve any medical and legal issues that could delay claim determination or facilitate a timely, safe return to work for the injured worker. The MCO may ask you to supply additional medical information to help support the claim or clarify medical issues related to the workplace injury. The MCO again will transmit this information electronically to BWC.

The question of allowance and causal relationship are medical issues that require your opinion for BWC to resolve. We must obtain evidence from a physician who has examined or treated the injured worker for the condition. BWC will allow a claim only for a work-related injury. The diagnosis reported must be causally related to the alleged accident. When the provider reporting the injury to the MCO includes a specific diagnosis in the report, or submits it soon thereafter, BWC can more quickly consider the diagnosis for allowance.

BWC considers both verbal and written documentation before making a decision that is impartial and objective, and based on Ohio law. Once we make the decision, one of our customer service teams must issue a written legal notice, BWC Order, to the injured worker and employer and their representatives. BWC electronically sends the claim, or medical condition allowance or denial to the MCO.

BWC’s goal is to determine claims within 18 days of receiving notice of the injury, 10 days earlier than the law requires. This means the injured worker will receive entitled benefits, and you will receive payment for your services quicker.

A 14-day appeal period follows this initial decision. If the injured worker and the employer agree, and both waive the appeal period, the claim becomes formally allowed. That means medical and compensation benefits can be paid.

When a claim becomes inactive, injured workers, employers and providers should contact the MCO to request further medical services.